Transcript Osteopathic Concepts of the Shoulder PPC/OMM Lab Christina

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Review relevant anatomy of the shoulder
Demonstrate a shoulder exam: Inspection,
Palpation, Rom, strength, and instability testing
Discuss physical exam findings including
osteopathic diagnosis of scapula, clavicle, AC,
and SC joints
Know common shoulder osteopathic treatment
techniques
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General
appearance
Inspection
Palpation
ROM
Strength
Stability
Special Testing
Neurovascular
Status
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Inspection
 Patient must be
exposed so that both
shoulders can be
viewed and
compared
 General appearance
 Look for asymmetry,
muscle atrophy,
ecchymosis, swelling
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Below is
“Sulcus” sign
indicates
multidirectional
instability
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Bony structures –
humerus, clavicle,
scapula
Muscles - Deltoid
and
”SITS”- Rotator
cuffSupraspinatus,
Infraspinatus,
Teres Minor,
Subscapularis
Acromioclavicular,
Sternoclavicular,
and
Glenohumeral joints
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External and
Internal Rotation
Flexion and
Extension
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ADduction
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ABduction
Don’t forget to examine the
proximal and distal joints
to the shoulder
(c-spine and the elbow)
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Shoulder pain may come
from the neck
 Radiculopathy
 Origin of trapezius,
levator scapulae
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Spurling’s maneuver
 reproduction of
shoulder/arm pain is a
positive test and
indicates a cervical
nerve root diorder
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Spurling's test: The examiner passively
hyperextends and laterally flexes the
patient's neck toward the involved side.
The test is positive if axial loading by
the examiner's hands reproduces
symptoms.
http://www.aafp.org/afp/991101ap/2035.html
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Spurlings Maneuver
Inspection & Palpation of Shoulder
ROM-compare both sides, look for restriction
Supraspinatus
 Test done in
“scaption”
 “Full can” or “Empty
can”
 Doctor pushes down
Positive test-when patient
has pain or weaknessindicates supraspinatus
tendinitis or muscle or
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Supraspinatus
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difficult to separately
test
Tests external rotation
strength
Stabilize the arm at the
elbow to prevent
abduction
 Pt externally rotates,
doctor internally rotates
 If pain-positive test
Patient
externally
rotates
Examiner
internally
rotates
Infraspinatus/Teres
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“Lift-off test”
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Best Test for subscapularis
Elbow at 90o; patient lifts arm off
of waist line against resistance.
Hard for patients with
impingement
Testing Against Belly
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Left Off Test
Close; less precise than “lift off”
Patient holds arm against
abdomen as shown; resists
examiner attempt to externally
rotate arm off of abdomen
Subscapularis Testing
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Anterior apprehension test
Arm in external rotation
 Abduction places pressure
on anterior shoulder
capsule
 Note examiner right hand
position which keeps the
shoulder from dislocating
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Relocation test
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Anterior to posterior
pressure is place by the
examiners right hand to
“relocate” shoulder – if
symptoms are relieved test
is positive
Anterior Release Test
Hawkins Test
Examiner exerts internal rotation
of humerus (blue arrow) with 90º
of forward flexion and 90º of
elbow flexion; a positive test is
reproduction of pain
Neer’s Test
In this test, the arm is placed thumb
down (internal rotation of humerus)
in scaption. Examiner stabilizes the
scapula border to prevent rotation.
The arm is raised in forward flexion
in scaption. A positive test is if pain
is reproduced.
1. Muscle Strength Testing
Supraspinatus,
Infraspinatus/Teres Minor
Subscapularis
2. Instability Testing
3. Impingement Testing
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Series of proprioceptive
neuromuscular facilitation
techniques
Can be expanded to include
ME treatment
Physician stabilizes scapula
Physician engages barrier of joint
Patient pushes against (away from
barrier)
 Repeat 3-5 times
 Taking up slack and engaging
new barrier each time
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Engages all of the muscles
around the GH joint
Both diagnostic & therapeutic
The seven stages of motions are:
1. Engage GH extension barrier
with elbow flexed
2. Engage GH flexion barrier with
the elbow flexed
3. Circumduction with
compression
 Start small circles, then gradually
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increase size
 Clockwise and counterclockwise
 May also do ME of IR/ER barriers
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4. Circumduction with
traction on straight arm
 Start small circles, then
gradually increase size
 Clockwise and
counterclockwise
5. Engage abduction
barrier
6. Adduction/IR with
elbow flexed
7. GH pump with
distraction and
compression along
straight arm
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Spencer technique
Humeral Head Anterior and Superior
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Physician can assess
for static/dynamic
asymmetry
Physician can
physically take scapula
through ROM,
assessing for
ease/restriction
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Patient in lateral recumbent position with
physician at side of table
Hook fingers of cephalad hand over superior
angle of scapula. Grasp elbow with opposite
hand, resting patient’s arm on physician’s
cephalad forearm (1)
Carry scapula inferiorly and laterally to
muscular restrictive barrier
Apply sufficient force to feel muscles relax
Force is slowly relaxed
Stretching repeated rhythmically until max
response obtained
Move fingers to medial scapular margin (2)
Carry scapula laterally and repeat #4-#6
Move fingers to inferior angle (3)
Carry scapula superiorly and laterally,
repeating #4-#6
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Sternoclavicular joint motions:
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Superior/Inferior glide
 Movement in the frontal (coronal) plane
 Also called ADduction/ABduction
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Anterior/Posterior glide
 Movement in a horizontal (transverse) plane
 Also called horizontal extension/horizontal flexion
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Rotation on its long mechanical axis
 Anterior (internal)/Posterior (external)
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Joint motions are coupled
 ABduction (IG) is coupled with posterior (external) rotation
 ADduction (SG) is coupled with anterior (internal) rotation
LATERAL
LATERAL
P
A
P
A
MEDIAL
MEDIAL
ABduction
Inferior Glide
Posterior Rotation
External Rotation
Horizontal Flexion
Posterior Glide
LATERAL
LATERAL
P
A
MEDIAL
ADduction
Superior Glide
Anterior Rotation
Internal Rotation
P
A
MEDIAL
Horizontal Extension
Anterior Glide
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ABduction (IG)/ADduction (SG)
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Physician stands at head of table
Patient is supine
Place tips of your fingers on the
superior edges of the medial
ends of the patient’s clavicle
Ask your patient to shrug their
shoulders. Both clavicles should
move into ABduction, and the
medial clavicles should move
inferiorly (inferior glide)
In the absence of trauma, the
dysfunctional (restricted)
clavicle stays superior at the SC
jointNamed an ADduction
somatic dysfunction (superior
glide)
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Horizontal Flex (PG)/Horizontal Ext (AG)
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Physician stands at head of table
Patient is supine
Place tips of your fingers on the anterior
edges of the medial ends of the patient’s
clavicle
Ask your patient to reach toward the ceiling
with their arms. Their scapulae should come
off the table. Both clavicles should move
into horizontal flexion, and the medial
clavicles should move posterior (posterior
glide)
In the absence of trauma, the dysfunctional
(restricted) clavicle stays anterior at the SC
jointNamed a horizontal extension
(anterior glide) somatic dysfunction
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Pt is seated and physician stands behind the patient toward the
side to be treated
Use hand closest to Pt. place the second metacarpophalangeal
joint over the distil third of the clavicle to be treated
Maintain constant caudad pressure over Pt. clavicle
With other hand grasp pt. arm on side to be treated below the
elbow.
Bring pt. arm toward flexion from adduction with a continuous
backstroke motion, the arm is circumducted toward extension
until it is at the side of the pt. The arm can be brought forward
and placed across the chest if this is comfortable for pt.
The release may occur before the barrier is met.
The physician reevaluates the dysfunctional (TART) components
Left Clavicle anterior and superior glide (SC Joint)
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Elevated SC joint-Articulatory
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Superior/Inferior Glide
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Physician places fingers on
distal clavicle at AC joint.
Palpate position of distal
clavicle in relation to acromion
Spring inferiorly on distal
clavicle to assess for motion
Assess for restriction of
gapping at AC joint.
AC gapping
External
Rotation
A
ADduction
P
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Pt. seated, physician stands behind the pt. toward the side being
treated
Physician, using the closest hand to pt., places the second
metacarpophalangeal joint over the distal third of clavicle being
treated
Physician’s other hand grasps the Pt. arm on side to be treated
below elbow
Pt arm is pulled down and then drawn backward into extension
with a continuous motion similar to throwing a ball,
circumducting the arm until it is once again in front of patient,
finishing with arm across chest in adduction
The release may occur before barrier is met
The physician reevaluates the dysfunctional (TART) components
Right Clavicle Superior Glide (at Lateral end of clavicle)
Elevated clavicle on Acromion(elevated AC joint)
Right Clavicle Superior Glide (AC)
1. SC assessment and treatment
2. Treat elevated SC joint
3. AC assessment and treatment
4. Treat elevated AC joint